چکیده انگلیسی

Little is known about the relationship between health anxiety and chronic pain. The present study explored whether individual differences in health anxiety would influence the response of chronic pain patients to physical therapy. Furthermore, the interaction of health anxiety with coping strategy usage (distraction versus attention) was studied. Participants were 81 chronic pain patients who were interviewed and completed measures of pain, anxiety and cognition following an active physiotherapy session in which they either: (1) attended to physical sensations; (2) distracted from physical sensations or (3) completed the session as usual. Health anxious, compared to non-health anxious, individuals worried more about their health and injury during the session and attended to and catastrophically misinterpreted sensations more frequently. A complex interaction between health anxiety and coping strategy emerged. Among health anxious patients, attention to sensations resulted in lower anxiety and pain than did distraction. It appears as though attention had a short-term anxiety reducing effect for health anxious patients. Among non-health anxious patients, attention resulted in greater worry about health than distraction. Clinical and theoretical implications are discussed.
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مقدمه انگلیسی

Health anxiety has been conceptualized as a dimensional construct that is characterized by extreme health anxiety or even hypochondriasis (excessive preoccupation with disease in the absence of supporting medical evidence or despite medical reassurance) at one extreme and complete lack of concern about one's health on the other Warwick, & Salkovskis, 1990 and Hitchcock, & Mathews, 1992. A Cognitive-Behavioural Theory (CBT) of health anxiety has been proposed (Warwick & Salkovskis, 1990). According to this theory, health anxious individuals form dysfunctional assumptions and beliefs about symptoms and disease based on past experiences and become health anxious when these dysfunctional schemata are triggered by critical incidents (e.g. hearing about illness, experiencing bodily sensations). Cognition is not only predicted to be prominent in the development of health anxiety, but is also expected to play an important role in the maintenance of the condition as well. Once health anxiety ensues, the theory further predicts that the health anxious person will manifest an attentional bias to notice illness information. Moreover, they will have a tendency to misinterpret somatic information as catastrophic and personally threatening (i.e. cognitive reaction). Considerable support for the cognitive response style among health anxious patients has been found through clinical observation (Salkovskis & Warwick, 1986), questionnaire studies (Kellner, Abbott, Winslow & Pathak, 1987; Jones, Mabe & Riley, 1989), studies examining cognitive biases (Hitchcock & Mathews, 1992), and quasi-experimental studies examining cognitive responses to experimentally induced pain (Hadjistavropoulos, Craig & Hadjistavropoulos, 1998).
Recently, it has been suggested that health anxious individuals may not only have a bias to negatively attend to and interpret somatic sensations, but they may also be deficient in strategies that protect them from health anxiety. Hadjistavropoulos et al. (1998), for instance, found that in a non-clinical sample health anxious individuals were deficient in their capacity to objectively monitor somatic sensations while experiencing experimentally induced pain. Non-health anxious individuals, on the other hand, utilized an objective monitoring style (i.e. a focus on the objective, concrete and nonemotional aspects of the symptoms as manifested in cognitions such as “it is a tingling sensation”) when exposed to pain. Previous research shows that those who use such an objective monitoring strategy during a noxious event experience benefits including increased pain tolerance and threshold as well as improved recovery from pain Blitz, & Dinnerstein, 1971, Ahles, Blandard, & Leventhal, 1983 and Cioffi, & Holloway, 1993. Hadjistavropoulos et al. (1998) proposed an extension to the CBT and suggested that health anxious persons may be deficient in their ability to engage in objective somatic monitoring. Here, the question remains whether this finding would hold in a clinical sample.
A further cognitive strategy that could be predicted to play a role in the experience of health anxiety is cognitive avoidance or suppression. The cognitive-behavioural theory of health anxiety (Salkovskis & Warwick, 1986) suggests that health anxious individuals will physically avoid information or situations that evoke health anxiety. Whether this would extend to the usage of cognitive avoidance, such as distraction or the suppression of anxiety provoking thoughts, in order to avoid health anxiety is unclear. If cognitive avoidance is present among health anxious individuals it could actually serve to increase health anxiety in the long run. Counter to what might be expected based on common sense (Leventhal, 1992), cognitive avoidance/distraction as a coping strategy seems to lose its advantages after a brief period and tends to be associated with greater disability and pain in those who favor this approach (Mullen & Suls, 1982). Suppression of thoughts, that relate to physical sensations, tends to result in a longer recovery period from pain and increases the probability that innocuous physical sensations (e.g. vibration) will be perceived as unpleasant (Cioffi & Holloway, 1993). Moreover, efforts to suppress such thoughts increases the likelihood of unwanted cognitions (Wegner, Schneider, Carter & White, 1987). Based on these findings, it could be predicted that efforts to avoid pain through suppression or distraction may prolong it and, thus, exacerbate health anxiety. To date, no research has explored this possibility within a clinical sample.
Overall, there appears to be a need to study cognition further among health anxious persons, particularly in a clinical setting. A clinical context that was thought to be useful for the examination of health anxiety is the study of musculoskeletal pain patients who are undergoing physical therapy. Preliminary research suggests that health anxiety may be important in understanding the way people respond to chronic low back pain. Low back pain patients who score high on health anxiety report greater somatic awareness, depressive symptoms and disability (Main & Waddell, 1987). Research also suggests that physical therapy and examination elicit considerable anxiety in patients (Hadjistavropoulos & LaChapelle, in press).
One goal of the present study was to explore more systematically the role of health anxiety in chronic pain. In particular, it was of interest to explore whether non-health anxious and health anxious patients would show variable cognitive responses during physical therapy. In line with the CBT and extrapolating from existing literature the following hypothesis was made:
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Health anxious patients were predicted to report greater pain, more somatic symptoms, higher anxiety and worry about health and injury, more catastrophic thoughts about pain, greater cognitive avoidance (e.g., attempts to ignore, distract from pain), greater negative somatic monitoring of symptoms, and lower usage of concrete objective somatic monitoring of pain than non-health anxious patients.
A second goal of this study, was to explore the impact of varying attentional focus either away from pain (distraction) or toward pain (attention) on response to pain, anxiety and cognition among health anxious and non-health anxious patients. Little attention has been given to how health anxiety may interact with cognitive coping strategies in determining one's response to pain. We attempted to disentangle the relation of distraction versus attention to sensations and health anxiety through the experimental manipulation of cognitive coping strategy in a sample of musculoskeletal patients differing in health anxiety. An interaction between health anxiety and cognitive coping strategy was hypothesized.
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Among health anxious patients, it was predicted that distraction would result in negative consequences for patients since previous research has shown that this strategy quickly becomes ineffective and results in increased pain and a greater number of negative intrusive thoughts (Cioffi & Holloway, 1993). Attention was also predicted to be detrimental because health anxious patients were predicted to respond to this instructional set by focusing on the negative somatic experience and by having catastrophic thoughts about injury.
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We further hypothesized that among non-health anxious individuals, the attentional condition would result in greatest benefits for patients since non-health anxious patients were expected to focus on concrete objective somatic symptoms rather than on negative aspects of the experience. This strategy has been found previously among non-health anxious individuals (Hadjistavropoulos et al., 1998) and typically aids coping with pain (Cioffi & Holloway, 1993).
In summary, this study examined the way health anxious and non-health anxious individuals respond while undergoing active physical therapy. Pain levels, control, anxiety and cognitive activity were studied under three conditions: (a) attention/monitoring, (b) distraction/avoidance and (c) a control condition. The control condition was thought to provide information regarding typical patterns of responding, while the experimental conditions were expected to provide information regarding the specific effects of coping responses on pain, anxiety and cognition.

نتیجه گیری انگلیسی

Preliminary analyses
The chi square statistic and multivariate analysis of variance (MANOVA) were used to examine whether patient groups (i.e. health anxious versus non-health anxious) and experimental conditions (attention versus distraction versus control) differed on background variables. Chi squares were used for categorical variables (i.e. marital status, sex, availability of job to return to, third party payer, multiple diagnoses, surgery as a result of the injury, previous injuries) while MANOVA was used for continuous variables (i.e. age, education, socioeconomic status, years at job, duration of pain complaint, amount of medication taken the day of the study, number of weeks on the program). No significant differences among patient groups or experimental conditions were identified (p's>0.10).
3.2. Manipulation check
Two seven-point Likert items were used to assess the extent to which participants followed the experimental instructions to either distract or attend to sensations. All participants reported that they had used the coping strategy to which they were assigned with moderate frequency during the sessions (M=3.91, S.D.=1.57). They also felt they were moderately effective in using the assigned strategy (M=3.57, S.D.=1.54). A 2 (health anxious versus non-health anxious)×2 (distraction versus attention) MANOVA examined whether groups differed in their frequency of usage or perceived effectiveness of employing the assigned strategy. The results were not significant (p's>0.20).
3.3. Questionnaires
A 2 (health anxious versus non-health anxious)×3 (attention versus avoidance versus control group) MANOVA examined whether groups differed on measures of pain (MPQ sensory and affective pain ratings), control (Likert questions asking about ability to control pain and decrease pain), anxiety (BAI, Likert questions asking about worry about injury and health) and cognition (CSQ subscales). The Wilks criterion was used for the assessment of multivariate significance. Means and standard deviations for all variables entered into the MANOVA are presented in Table 1. The MANOVA revealed a main effect for strategy, F(28, 124)=1.70, p<0.03. None of the follow-up univariate tests examining this between-subjects effect, however, reached statistical significance (p's>0.10)